Medical ConditionsCardiac & respiratory: Asthma

Asthma

Overview

Board takeaway: Defer elective care during wheezing or poor control; have the rescue inhaler and spacer ready and review drug triggers before treatment.

The most common chronic disease of childhood.

How does Asthma affect dental management?

Rescue readiness: Keep the prescribed rescue inhaler and spacer available; follow the medical asthma action plan for pretreatment medication
Anxiety and nitrous: Reduce anxiety; consider nitrous oxide for well-controlled asthma after airway assessment; defer during active wheezing
Triggering drugs: Avoid NSAIDs in aspirin-sensitive asthma; avoid narcotics that release histamine (morphine, meperidine)
Local anesthesia: Ask about documented sulfite sensitivity: vasoconstrictor-containing local anesthetics contain sulfite preservatives.
Diagnostic limit: Asthma alone does not establish sulfite allergy
Steroid history: Patients on chronic systemic steroids may need stress dosing (see adrenal insufficiency)
After inhaled steroids: Rinse and spit after inhaled steroids and use a spacer to prevent candidiasis
Acute attack: stop, sit upright, give prescribed inhaled albuterol with a spacer and oxygen as indicated; activate EMS for severe symptoms or poor response. IM epinephrine is indicated if anaphylaxis is suspected

Loading diagram…

Active wheezing or suspected anaphylaxis stops elective dental care. Severe symptoms or poor response require EMS; suspected anaphylaxis requires IM epinephrine and emergency care.

NHLBI EPR-3, acute assessment.

Exam pearl

What is Asthma?

A chronic inflammatory airway disorder with heightened airway responsiveness and variable airflow obstruction, producing episodes of wheezing, cough, chest tightness, or shortness of breath.

What are the main systemic features of Asthma?

Airway disease: Chronic airway inflammation with reversible bronchoconstriction; affects ~8% of US children
Triggers: viral infections, allergens, smoke, cold air, exercise, stress, NSAIDs in some patients
Controllers: inhaled corticosteroids, leukotriene modifiers, and long-acting beta agonists (LABAs) used with inhaled corticosteroids. LABAs must not be used alone for asthma. FDA safety communication.
Relievers: short-acting beta agonists (albuterol)

What oral findings occur in Asthma?

Caries and erosion: Caries and erosion risk may rise with dry mouth, mouth breathing, diet, reflux, or medication formulations; assess the actual exposures
Candidiasis: Oral candidiasis from inhaled steroids
Gingiva: Gingivitis and more calculus; mouth breathing
Occlusion: A long-face pattern, high palate, crossbite, or increased overjet may accompany chronic mouth breathing; these are not specific signs of asthma

For Asthma, what do you do when the child starts wheezing?

Stop, remove materials from the mouth, and sit upright. Give prescribed inhaled albuterol with a spacer according to the child’s action plan. In an acute-care setting, the NHLBI pediatric regimen uses 4–8 puffs (90 mcg/puff) every 20 minutes for 3 initial doses, then every 1–4 hours as needed under medical care. Do not wait to complete three doses before activating EMS for severe symptoms. NHLBI dosing table.
Oxygen as indicated; activate EMS for severe symptoms/distress or poor response
IM epinephrine if anaphylaxis suspected

For Asthma, how do you assess an asthmatic child before treatment?

Control: daytime and night symptoms, weekly rescue-inhaler use, emergency visits or hospital stays, and oral steroid bursts in the past year.
Treatment and triggers: current controller medications and known triggers.
Readiness: have the patient bring the rescue inhaler and spacer. Defer elective care for wheezing or poor control.

What additional precautions are needed for a patient with asthma who takes high-dose inhaled steroids and frequent oral steroids?

Review exposure: Review dose, duration, steroid bursts, symptoms, and any previous adrenal testing.
Why: High-dose inhaled and repeated systemic steroids can suppress the HPA axis.
Coordinate the plan: Coordinate with the prescribing clinician and anesthesia; exposure alone does not determine a stress-dose regimen.
Established insufficiency: If adrenal insufficiency is established, use its written dental and perioperative plan.

Sources

How does Asthma affect dental management?

Rescue readiness: Keep the prescribed rescue inhaler and spacer available; follow the medical asthma action plan for pretreatment medication

Anxiety and nitrous: Reduce anxiety; consider nitrous oxide for well-controlled asthma after airway assessment; defer during active wheezing

Triggering drugs: Avoid NSAIDs in aspirin-sensitive asthma; avoid narcotics that release histamine (morphine, meperidine)

Local anesthesia: Ask about documented sulfite sensitivity: vasoconstrictor-containing local anesthetics contain sulfite preservatives.

Diagnostic limit: Asthma alone does not establish sulfite allergy

Steroid history: Patients on chronic systemic steroids may need stress dosing (see adrenal insufficiency)

After inhaled steroids: Rinse and spit after inhaled steroids and use a spacer to prevent candidiasis

Acute attack: stop, sit upright, give prescribed inhaled albuterol with a spacer and oxygen as indicated; activate EMS for severe symptoms or poor response. IM epinephrine is indicated if anaphylaxis is suspected

Loading diagram…

Active wheezing or suspected anaphylaxis stops elective dental care. Severe symptoms or poor response require EMS; suspected anaphylaxis requires IM epinephrine and emergency care.

What are the main systemic features of Asthma?

Airway disease: Chronic airway inflammation with reversible bronchoconstriction; affects ~8% of US children

Triggers: viral infections, allergens, smoke, cold air, exercise, stress, NSAIDs in some patients

Controllers: inhaled corticosteroids, leukotriene modifiers, and long-acting beta agonists (LABAs) used with inhaled corticosteroids. LABAs must not be used alone for asthma. FDA safety communication.

Relievers: short-acting beta agonists (albuterol)

What oral findings occur in Asthma?

Caries and erosion: Caries and erosion risk may rise with dry mouth, mouth breathing, diet, reflux, or medication formulations; assess the actual exposures

Candidiasis: Oral candidiasis from inhaled steroids

Gingiva: Gingivitis and more calculus; mouth breathing

Occlusion: A long-face pattern, high palate, crossbite, or increased overjet may accompany chronic mouth breathing; these are not specific signs of asthma

For Asthma, what do you do when the child starts wheezing?

Stop, remove materials from the mouth, and sit upright. Give prescribed inhaled albuterol with a spacer according to the child’s action plan. In an acute-care setting, the NHLBI pediatric regimen uses 4–8 puffs (90 mcg/puff) every 20 minutes for 3 initial doses, then every 1–4 hours as needed under medical care. Do not wait to complete three doses before activating EMS for severe symptoms. NHLBI dosing table.

Oxygen as indicated; activate EMS for severe symptoms/distress or poor response

IM epinephrine if anaphylaxis suspected

For Asthma, how do you assess an asthmatic child before treatment?

Control: daytime and night symptoms, weekly rescue-inhaler use, emergency visits or hospital stays, and oral steroid bursts in the past year.

Treatment and triggers: current controller medications and known triggers.

Readiness: have the patient bring the rescue inhaler and spacer. Defer elective care for wheezing or poor control.

What additional precautions are needed for a patient with asthma who takes high-dose inhaled steroids and frequent oral steroids?

Review exposure: Review dose, duration, steroid bursts, symptoms, and any previous adrenal testing.

Why: High-dose inhaled and repeated systemic steroids can suppress the HPA axis.

Coordinate the plan: Coordinate with the prescribing clinician and anesthesia; exposure alone does not determine a stress-dose regimen.

Established insufficiency: If adrenal insufficiency is established, use its written dental and perioperative plan.